UNITED STATES MARINE CORPS
Field Medical Training Battalion
Camp Lejeune
FMST 1407
Manage Musculoskeletal Injuries
TERMINAL LEARNING OBJECTIVES
1. Given a casualty with musculoskeletal injuies in a combat environment and standard field
medical equipment and supplies, manage musculoskeletal injuries, to prevent further injury
or death. (FMST-HSS-1407)
ENABLING LEARNING OBJECTIVES
1. Without the aid of references, given a description or list, identify the anatomy of the
musculoskeletal system, per the student handout. (FMST-HSS-1407a)
2. Without the aid of references, given a description or list, identify standard medical
terminology related to the musculoskeletal system, per the student handout. (FMST-HSS1407b)
3. Without the aid of references, given a description or list, identify the type of
musculoskeletal injuries, per the student handout. (FMST-HSS-1407c)
4. Without the aid of references, given a description or list, identify the treatment for
musculoskeletal injuries, per the student handout. (FMST-HSS-1407d)
5. Without the aid of references, given a description or list, identify the general rules for
splinting, per the student handout. (FMST-HSS-1407e)
6. Without the aid of references, given a description or list, identify the three types of splints,
per the student handout. (FMST-HSS-1407f)
7. Without the aid of references, given a simulated casualty with musculoskeletal injuries and
standard field medical equipment and supplies, manage the casualty, per the student
handout. (FMST-HSS-1407g)
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1. ANATOMY
The Skeletal System - composed of all the bones, joints and muscles of the body, as well as
cartilage, tendons and ligaments. Bones are formed of dense connective tissue. As
components of the skeleton, they provide the body’s framework. They are strong in order to
provide support and protection for the internal organs, but they are also flexible to withstand
stress.
Axial Skeleton - consists of the skull, spinal column, and rib cage.
Appendicular Skeleton - consists of the upper extremities to include the scapula and
bones of the lower extremities to include the pelvic girdle.
Appendages:
Upper extremities - made up of the humerus, ulna, radius and bones of the wrist and
hand
Lower extremities - made up of the femur, tibia, fibula and bones of the ankles and
feet
Types of Bones - there are four types of bones that are classified by shape (see figure 1):
Long bones - such as the femur and humerus
Short bones - such as the wrist and ankle bones
Irregular bones - such as vertebrae, mandible and pelvic bone
Flat bones - such as the sternum and skull
Figure 1. Bones Classified By Shape
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Muscular System
Muscles - tissue fibers that
cause movement of body parts
or organs. There are three kinds
of muscles (see figure 2).
Skeletal (voluntary)
Smooth (involuntary)
Cardiac (myocardium)
Figure 2. Three Types Of Muscle
Cartilage - connective tissue covering the outside of bone ends and act as a surface for
articulation.
Tendons - bands of connective tissue that bind the muscle to bones.
Ligaments - connective tissues that support joints by attaching the bone ends and
allowing for stable range of motion (see figure 3).
Figure 3. Tendons and Ligaments
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2. TYPES OF MUSCULOSKELETAL INJURIES
Soft Tissue Injuries - involve the skin and underlying musculature, commonly referred to as
either a closed or open wound.
Closed - an injury where there is no open pathway from the outside to the injured site (see
figure 4).
Open - an injury in which the skin is interrupted, or broken, exposing the tissues
underneath (see figure 5). Open wounds include abrasions, lacerations, avulsions, and
amputations.
Figure 4. Closed Wound
Figure 5. Open Wound
Abrasions
Figure 6. Abrasion
Definition - superficial scratches of the skin’s
surface. Also called "brush burns," "mat burns,"
and "road rash." Some bleeding may result, but
usually oozes from injured capillaries.
Extremely painful because nerve endings are
involved (see figure 6).
Treatment:
- Hemorrhage is usually so minimal that
primary treatment may only require
cleansing of the wound.
- Small bandages may be applied but
Figure 6. Abrasion
tactical situations will usually preclude
applying field dressings that are needed for more serious injuries.
- A large amount of dirt may be ground into the wound, therefore secondary treatment
measures should focus on preventing or stopping infections.
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Lacerations
Definition - a laceration is a cut. It may be smooth or jagged and
can be caused by an object with a sharp edge or may result from
a severe blow or impact with a blunt object (see figure 7).
Treatment - treatment is generally the same as for abrasions:
- Control hemorrhage
- If major tendons and muscles are completely severed,
immobilize limb to prevent further damage.
- Treat for shock
- Consider CASEVAC
Avulsion
Figure 7. Laceration of the
Lower Arm
Definition - an injury in which flaps of skin are torn loose or completely pulled off (see
figure 8).
Treatment
- Control bleeding
- Apply field dressing to avulsed area.
(For extremely large or deep
avulsions, several pressure
dressings may be necessary or an air
splint and dressing).
- Prevent further contamination.
- Ensure avulsed flap is lying flat and
that it is aligned in its normal
Figure 8. Avulsion of the palm
position.
- If the avulsed part is completely pulled off, make every effort to preserve it. Wrap
the part in a saline or water soaked field dressing, pack wrapped part in ice, and
whenever possible be careful to avoid direct contact between the tissue and ice.
- Transport the avulsed part to the BAS with the patient but keep it well-protected
from further damage and out of view of the patient.
- Immobilize extremity or body part as indicated by the severity of the avulsion.
Amputations
Definition - removal of a limb or other
appendage of the body. May be removed
surgically or traumatically. Because blood
vessels are elastic, they tend to spasm and retract
into surrounding tissue. With complete
amputations there is less bleeding then with
partial or degloving cases (see figure 9).
Figure 9. Traumatic amputation of the lower legs.
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Treatment
- Hemorrhage Control - Apply a tourniquet. If a tourniquet is applied, mark the
patient's forehead with a "T" (indicating the time it was applied).
- Place the patient in shock position. (Head down, feet elevated)
- Make every effort to preserve the amputated part and evacuate the patient as soon as
possible.
- Wrap amputated part in sterile dressing, place in ice and send with patient. When
possible, prevent direct contact between tissue and ice.
Strains, Sprains and Dislocations
Strain - injury to a muscle or tendon
resulting from over stretching or overexertion.
Sprain - a joint injury resulting in partial
tearing or stretching of supporting ligaments
(see figure 10).
Dislocation - the displacement of bone ends
at the joints resulting in an abnormal
stretching of the ligaments around the joints.
Sometimes causes tearing or complete
ligament separation (see figure 11).
Signs and Symptoms
- Point tenderness or burning
sensation
- Marked deformity of joint
Figure 10. Ankle Ligament Sprain
- Pain and edema
- Complete or near complete loss of movement of joint
Treatment
Strains Sprains:
- Supportive strapping or
bandaging
- Immobilize by splinting so
that affected muscle is in
relaxed position, if injury is
severe
-R.I.C.E. (Rest, Ice,
Compression, Elevation)
Dislocations:
Figure 11. Ankle Dislocation
- Attempt to reduce only if no
pulse is present in the extremity. If patient can be CASEVAC’ed quickly, the
better decision may be to transport rather than attempt manipulation.
- Splint, as found, to immobilize injured part.
- Pain management
- CASEVAC
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Complications
Hemorrhage - caused by separated bone ends tearing muscle tissue and laceration
of blood vessels
Nerve Damage - due to the cutting or pinching of nerves by seperated bone ends or
muscle injury
Fractures
Definition - a break in the continuity of the bone. This may result in partial or complete
disruption of the bone. May be classified as either open or closed (see figure 12):
Open fracture - initial injury or bone end has produced an
open wound at or near the fracture site.
Closed fracture - the bone is broken with no skin penetration
Signs and Symptoms
- Discoloration
- Deformity
- Edema
- Crepitus/grating
- Point tenderness
- Limited range of motion
- Direct or indirect pain
- Exposed bone fragments (open fractures)
Open
General Principles of Treatment for Fractures - the
following guidelines can be applied to any type of fracture,
regardless of location:
Closed
Figure 12. Open/Closed Fracture
- Treat associated injuries
- Control hemorrhage
- Treat for shock
- Check distal pulses before and after splinting
- Immobilize the fracture using splints
- Recheck PMS (Pulse, motor, and sensation)
- Relieve pain (see medication appendix at the back of Block 2 for more information)
- DO NOT reduce fractures in field unless distal pulses are not present
- Monitor and CASEVAC
3. SPLINTS AND SPLINTING
Definition - an appliance made of wood, metal or plaster used for the fixation, union or
protection of an injured part of the body.
Purpose
- To immobilize the injured body part
- To prevent further damage to muscles, nerves, or blood vessels caused by broken ends
of bone
- To prevent a closed fracture from converting to an open fracture
- To decrease pain
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General Rules for Splinting
- Control hemorrhage. Direct pressure and/or pressure dressings will control vitually all
external hemorrhage encountered in the field.
- Expose fracture site. Remove jewelry and watches.
- Before splinting, establish distal pulse.
- Splint in the position found unless limb is pulse-less.
- An attempt should be made to straighten a SEVERELY deformed limb with gentle
traction only if there are no distal pulses, if resistance is felt, stop and splint as it lies.
- Move the fractured part as little as possible while applying the splint.
- DO NOT retract the exposed bone of an open fracture back into the body.
- Pad splint at bony prominence points (elbow, wrist and ankle).
- Splint the joints above and below the fracture site.
- Reassess circulation and neurological status after splinting.
- When in doubt treat as a fracture.
Anatomical Splints - use of the
patient's body as a splint (see figure 13).
- Strap legs together
- Secure arm to chest
- Secure arm to the body (for
fractured arm/ribs)
- Tape fingers together
Figure 13. Anatomical Splint
Improvised Splints - made from any available material that
can be used to stabilize a fracture. The only limitation to
improvised splinting is your imagination and creativity (i.e.
sticks/branches, blankets, tent poles, see figure 14)
Manufactured Splints - manufactured splints are generally
designed for specific injuries, thus they are applied in specific
ways.
Soft Splint - the soft splint can be used to splint various
fractures throughout the body (see figure 14).
Purpose - used to immobilize fractures and suspected
Figure 14. Improvised/ Soft Splint
fractures of the neck, back, arms, and legs.
Description - a wrap around, non-rigid splint that limits motion in the area applied
commonly made from items such as pillows, ponchos, and blankets.
Rigid Splint/ SAM Splint
Purpose - used to immobilize suspected fractures.
Description - a rigid splint that prohibits motion in the area applied.
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Air Splints
Purpose - used to immobilize arms and legs (see
figure 15).
Description - a pre-formed, one piece, clear plastic,
balloon-like envelope with a zipper, string, velcro,
or combination of these for closure.
- If splint is used in aircraft, some air may have
to be released as plane gains altitude.
- This splint is inflatable (be careful not to over
inflate the splint).
Figure 15. Air Splint
Splinting for Specific Types of Fractures
Fractured Clavicle - immobilize using a figure eight bandage.
Fractured Humerus - splint to body using full arm wrap leaving elbow exposed.
Fractured Radius/Ulna
- Splint from wrist to elbow.
- Place patient's hand in top of jacket for elevation and support.
- Sling arm using a cravat to cradle elbow and tie around neck for immobilization.
Fractured Wrist/Hand
- Splint in position of function, leaving fingers exposed to check circulation.
- Place patient's hand in top of jacket for elevation and support.
Fractured Ribs
- Single closed rib fractures - do not bind or strap around chest.
- Multiple fractures - immoblize flailed segments, do not hinder breathing. Sling and
swathe arm to injured side of chest to reduce motion and pain. Do not hinder
breathing!
Fractured Pelvis - consider wrapping bed sheet tightly around lower aspect of pelvis and
tying it as a sling.
- Strap knees and ankles together.
- Place pad around bony prominences and soft pad under knees.
Fractured Femur - immobilize fractured leg by splinting one leg to the other with five ties.
- One above wound
- One below wound
- One above the knees
- One below the knees
- One around feet to secure ankles/boots
Fractured Patella - splint to other leg using four ties:
- One around the thighs
- One above the knee
- One below the knee
- One around the ankles
Fractured Tibia/Fibula - splint one leg to the other with four cravats or improvised ties:
- One above wound.
- One below wound.
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- One around the thighs
- One around feet to secure ankles/boots
Fractures of Ankle/Foot - immobilize using soft splint or uninjured extremity and four
cravats:
- One above the ankle
- Figure eight bandage around the ankles
- One below the knee
- One above the knee
CASUALTY ASSESSMENT AND MUSCULOSKELETAL INJURIES
Care Under Fire Phase: In the absence of life-threatening hemorrhage from a musculoskeletal
injury, the material in this section is unlikely to be addressed in Care Under Fire. If the casualty
does have life-threatening hemorrhage, use a tourniquet for extremity injury or a hemostatic
dressing like HemCon or QuikClot with direct pressure for torso injuries
Tactical Field Care Phase: During this phase, you will be required to inspect the injury using
DCAP-BTLS for any signs of injury. Note and treat all musculoskeletal injuries. Complete a
head to toe assessment using DCAP-BTLS noting and treating additional injuries. Determine if
vascular access is required (see Combat Fluid Resuscitation lesson) and give fluids if necessary.
If the casualty is able to drink fluids, they should be encouraged to do so. Consider pain
medications and give antibiotics if warranted. Reassess all care provided. Document care given,
prevent hypothermia, and CASEVAC.
REFERENCE
Pre-Hospital Trauma Life Support, Military Edition, 6th Ed, Chapter 12
REV: July 2008
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Musculoskeletal Injuries Review
1. Define an open injury and list four examples.
2. Describe the differences between a complete amputation and a partial amputation.
3. List the first four general rules of splinting.
4. Identify the appropriate treatment for a fractured pelvis.
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